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A32 128. � . Person County Health Department Sewage System Improvements Permit Date: -Z7�� This Permit Void After 5 Years Owner: %��w�v�'s 1. illo�n; t SR# �l1Ul Location/Directions: �f7.�.,. _ /��•-d� /'7•°//s �b ,• �.,��r S�.K Subdivision Name: N1� ''��r' �"�" ot # NA Lot Size: �• �� Type of Dwelling: M� o _ Water Supply: Privatc: � Public: Community: Bedrooms: � Garbage Disposal Na . Basement � Basement Fixtures /1/O � � INFORMATION1 /�C/E�RTIFIED BY ;� ' , , �i cv��. S�LIli�I1�I1: �-tX� ��C�vr,w,�� ouner or represe tive � REPAIR: REEVALUATION: �. ------------------------- Size of Septic Tank: O� gallons Size of Pump Tank: "'' Nitrification Line: � E3' 3�� j�, Depih of Stone: 12 inches Max Depth of Trenches: ��,G, Z- . Altemative System: Conv. Pump "—" LPP Pomp + Remarks: ti�' C"�� NC�cr��$ JQ�- --------------------------- Date Well Approved: Well should be 100 fG from any sewer system BY Sanitarian D e Sewa yst pproved: �— �<— � d�-- BY Sanitarian � � „��yE � FI��['E�F COMPLETION Contractor. tp�C! y� �� .�t l ------------------------- '-3 w Sewage System location, installation, and protection must meet state and local '� regulations. Sepdc tank should be pumped out every 3 to 5 years and shall be maintained � by owner in such manner as not to create a public health hazard. Septic tank and'b nitrificauon line must be inspected and approved by a member of the Person County � Health Department before any portion of the installation is covered and put into use. If the site plans or intended use change this permit is subject to revocation. � (G.S. 13U A-335F) � Location of sewage disposal sewage system sketched on back. �� (OVER) '� ' � :� . ' PeY`�on County Health Department � Weli Permit � Date• Z-Z� This Permit Void After 3 Years '� Owner: .� ��%S 1. �v n; SR# /UOl �.00aIlOylilimrrinnc• %�i ,S I�lul��. rli��.S �o �otiZ+��"v ��w _ L.L �� d u I�G 1'l' i.S Q�. �� uY�t ei.r OiS� � Subdivision Name: .VA Lot # � Drilling Contractor: WELL CO STRU ON ►� Distance from Nearest Property Line .� � Distance from Source of �' Pollurion I d � c� Total Depth: ��5 Ft Yeld: �GPM Static Water Level 5� FG � Water Bearing Zones: Depth .35 �'G FG �5� FG t. Casing: Depth: From _� tb'�� FL Diameter: C•.� � Inches TYPE: Steel � Galvanized Steel - � If Steel, does owner approve: Yes `� No _r �� ches Weight: Thiclrness: Height Above Groun : Drive Shce: Yes ✓ No Were Problems Encountered in Setting the Casing? Yes No r—� If "yes" give reaso� 'b Grou� Type: Neat Sand/Cement Concrete � Annulaz Space Width 3 Inches Water in Aimular Space: Yes '� No Method: Pumped Pressure Poured � Depth: Fmm (�_ to �_� Materials Used: No. Bags Pordand Cement _�� Weight of 1 bag �� lbs. ��— If mixhue (sand, gravel, cut�ngs) - Ratio: ` to �_ ID Plates: Yes � No ►d 4 z 4 slab Yes No ��" . De th ' .� I HEREBY CERTIFY THAT THE ABOVE INFO ATIO ORRECf AND THAT 'THIS WELL WAS CONSTRUCTED IN ACCO REGULATIONS SET FORTH BY THE PERSON COUNTY RTME . 1' ` � :.�� gnanae f Contractor Date �� 4o�r.,... /Z-27-q1 Sanitarian's Sign re Date Issued Sanitarians Signature Date Completed Sketch well location on reverse side. v" i � NOTE: Make sketch of installation showing lot size and shape, location of house, septic tanks, privies, water supplies, etc. Note special problems existing on lot. Write in measurements in order that installations may be located at later date. Nofe location of water supplies on adjacent lots. (1) _ .� (2) ■■SB■�■.■■■■■�;■■■■■■■■■■.■ ■■�■■■�■■■■■.■ ■■�■■.■■■■■■. ■■�■.�■■.■.�■� ■.■■�■■■■■■■. ■�■■■■■■■■■■ ■'.■■■■■■�■■■■ ■■■■■■■■�� . ■.■�■■�■■■■■ ■■�■■■■.■■■■■■ ■■■■� ■■■■■■■ ��e��■ s■��■ ■��■■ ■��_��■��■ ��s�■ �� ■��■��■ ■��■�■ ■��■��■ ��■��n�■ ■o�� ■■ � F-+ O a � w U � ii �.i, °0 �q�l �e �s�-�`r�� " / � • � 8' -3 0. - � ,j�� Improvements Permit (Established/Recorded Lot) I_ Reinspection of Existing System (Loan Closing) Improvements Permit (Unrecorded Lot) Improvements Permit (Mobile Home Replace) Improvements Permit (Addition) Repair/Replace existing Septic System Permit for New Well _ Replace Existing Well 1. Permit requested by: owner/prospective owner/agent:� - i�R Address: 3k+-�'i C��,�,.�Jr" G��,�-e CAu.� �� 1, . � �1 Or //Yl.'� (� � I. C. , 27_Sy l ne Phone �'iloi�;�y-�-S3� � iness Phon�e #�y 15, qy Z-`-�� `f � � Iq' �� 1,7 Name and address of current owner: SaM� 7. Dimensior�s or Proposed Structure: �� Widch: 3(� (� ep 1 ae.2 Denth: 3 a' V.�/ j�0 c,1 S�-- 8. What type (if any, additions, expansions, or replacement is anticipated to the structure or facility that this sewage disposal system is intended to serve? 9. Water supply type: private CY public ❑ community ❑ spring ❑ Are any wells on adjoining property?Yes ❑ No C" If so, identify location: Property Description: Lot size: Tax Map#: �} 3 2 10. Type of structure/facility: Proposed: �Existing: ❑ Parcel#: l% S Type of dw,�el�l` g: Township: I� .c�� 2 _ House: l� Mobile Home: �usiness: ❑ . Directions to property: State Road #& Road ames, etc. � o a o �-► ��.,,,� Number of occuvants or people to be served: � Type of business: Number of Employees: Number of bedrooms: 3 Garbage Disposal? Yes ❑ No ❑ Basement? Yes L�' No ❑ If so, # of basement fixtures: CLEARLY STAKE ALL CORNERS OF THE PROPERTY AND THE CORNERS OF ALL PROPOSED STRUCTURES. I hereby make application to the Pet'son COunty Health Department for a site evaluation for the on-site sewage disposal system for the above described property. I agree that the contents of this application are true and represent the maximum facilities to be placed on the property. I understand if the site is altered or the intended use changes, the permit shall become invalid. I understand that before an Improvements Permit can be issued, I must present a survey plat of the property to the Health Dept. I understand that in the event I have not delivered a survey plat of the property to the Health Dept: within 60 DAYS after the date of the evaluation of the site by the Health Dept., this application shall become void and all fees paid forfeited. ! X��.�Yw�- � • ��.�UtA.I� Signed Owner or Authorized Agent 1 , . , . . . , .. Permit Issued ❑ Signature Permit Denied ❑ Plat Observed ❑ Date FACTORS-S1TE EVALUA7TDN AItFA l AREA 2::: AREA 3 AREA �F. .: _. __ . I. SLOPE (96) S S S .:: S.. . PS PS PS PS U U U U 2. SOII.7'E?CNRE(12-36IN.) S S S S (SAA'DY, LOAk1Y. CLAYEY, NOTE 2:l CLA1� PS PS PS PS U U U U 3. SOIL S'IRUCil1RE (12-36IN.) S S S S (CLAYEY SOII.S) PS PS PS PS U U U U 4. SOILDEPTH(WJ S S S S PS PS PS PS U U U U 5. RESTRICi7VE HORIZONS (IN.) S S S S (�1PERVIOUSSTRATA,ROCK) PS _ PS PS PS U U U U 6. SOIL DRAINAGF/GROUNDWATER S S S S (EXTERNAL & INTERNAL) PS PS PS PS U U U U 7. SOII. PERMEABILTCY S S S S (PERCOLOATION RATE) PS PS PS PS U U U U 8. AVAILABLE SPACE S S S S PS PS PS PS U U U U 9. SiTECLASSIFICATION(SEEBELOW) SOiL SERIES S-SUITABLE PS-PROVISIONALLYSUITA6LE U•UNSUITABLE RECOMMENDATIONS/COMMENTS: STTE CLASSIFICATION DIAGRAM (Include: Soil areas, property lines, roads, streams, gullies, wet areas, fill areas, wells, water bodies, slope patterns, etc.) C:�AMiPRO�DOCSWPPSEC.Sh1F(NANCE.PC � • .. . . . . i5m.0m' 1.�� f�CRE 1�21 SF � m � � 38' _�=.. % %% - C�„7� PERSON COUNTY HEALTH DEPARTMENT WELL AND SEWAGE SITE, LOCATION IMPROVEMENT PERMIT Tax Map # � 3� Parcel # � ��a� Zoning Township B�5 Owner/Contractor n� i D te f .S Location/Address u= 15'7 � I rt.l, c.�-rC (p i I l s L� �'n��►,�Fn, ��P �n s, R. (C1n! D�� J� o� f e-E-, S.R.# tob ( Subdivisioh Name a / �� j �;.t�'`a„r � n �(��; �� SEWAGE SYSTEM SPECIFICATIONS ��ti Re air Lot Area '', i [' �� Size of Tank i� n' Ob 't� SFD ✓ Mobile Home Size of Pump Tank ��) X� Business # of Bedrooms � Nitrification Line AcrG� /Ot►' X 3 fid �r�[ � � Max Depth Trenches o2l0 %n . Permit Void after 60 months. Permit Void if not in compliance with zoning regulations. Permits may be voided if site is alt red or ' tended us�,,c ang d. Well and Septic Layout by - r� Comments: Date/� �2.�''�/S Installed by J�'o�wc� 2, Well Permit Individual Publ ic Sit pprov ell He A Grout' � Ap� ��/�L SYSTEM _ emi-Public Replace � ECIFICATIONS Required S _ Air equired Wel Well Ta _ by Gt1. `�'� �9 �c.wc�-` Date // Inst�d by � /Approved)ay � This report is based in part on information provided the homeowner or his/her representative in the application submitte for this permit. The environmental health specialist is not responsible for false or misleading information contained in the application. The environmental health specialist is also not responsible for concealed conditions on the property or for statements in this report that may have resulted from false or misleading statements provided to him in the application. Neither Person County nor the environmental health specialist wamants that the septic tank system will continue to function satisfactorily in the future or that the water supply will remain potable. c:�amipro\permit.sam 01/95 rev.1.0 � � �� 3oc��,K 3s